IMAGES IN EMERGENCY MEDICINE

Acute abdomen in a young patient: the distant culprit A 24-year-old man presented with severe abdomen pain of 4 days dur-ation. He was an intravenous drug abuser without significant past illness. Examination revealed tachycardia, normal blood pressure and diffuse abdominal tenderness. Chest roentgenogram showed cardiomegaly. Contrast enhanced CT scan of abdomen showed short segment of intraluminal filling defect in the distal part of the superior mesenteric artery, just before its bifurcation, suggestive of thrombus (figure 1). It also showed peripheral poorly enhancing hypodense area of subsegmen-tal infarct involving cortical and subcortical region of lower pole of right kidney (figure 2) and a small peripheral poorly enhancing wedge shaped hypodense area of splenic infarct involving mid pole (figure 3). Hepatomegaly and dilated small bowel loops were also noticed. An echocardiogram was performed which revealed a dilated left ventricle with generalised hypokinesia and severe left ventricular systolic dysfunction with a long linear (4×0.9 cm) unusually mobile thrombus attached to anter-ior wall. (figure 4; see online supplementary videos 1 and 2). Left ventricular thrombus, a well recognised complication of a dilated dysfunctional left ventricle, embolises mostly to cerebral circulation. Embolisation of left ventricular thrombus to visceral organs occurs in less than 10 % cases and simultaneous embolism to renal, splenic and mesenteric arteries is even rarer and may be clinically misleading.